Research on the child healthcare system in China from the perspective of equal health benefits: Beijing as the case study

Abstract Background With government's proposal of the Healthy China Strategy, universal health has become the focus of increasing attention in China. As a special group, children's health is the basis and start of the national health. The construction of children's healthcare system should be given the priority. This study applied the concept of health equal benefits and conducted a systematic and in‐depth theoretical and empirical research on the children's healthcare system in Beijing, aiming at proposing relevant countermeasures and suggestions such as constructing the path of children's health care system in China. Methods This study adopted the way of questionnaire on children's basic information, health status, health service demand, insured situation and system satisfaction and then analysed the children's health, healthcare, satisfaction influence factors and their healthcare needs based on a survey in Beijing China. Methods such as descriptive statistics, analysis of variance and logistic regression are adopted to analyse the correlation between factors affecting children's health. Results The findings show that overall health of the children in Beijing was better. However, there are still problems such as insufficient resource coverage and incorrect cognition in some groups. Their mental health and support need to be put emphasis on. The popularization of medical insurance policies for urban and rural residents in Beijing needs to be further improved. The burden of seeing a doctor is slightly lower than before, and the contribution to protecting children's health is not strong enough. Conclusions Through the survey of children in Beijing, it can be seen that there are still some problems existing in the healthcare system of children in China from the perspective of equal benefit. This study draws policy attention to the issues of financing, service contents, targets, service level and the degree of social recognition.


| INTRODUCTION
Healthy China Strategy has emphasized the importance of healthcare to the national strategic level to achieve the transformation from medical insurance system to healthcare systems (Xi, 2017). Children are the future of the country and the nation, and their healthy growth is also related to the stability and happiness of every family. According to data from the official website of the National Bureau of Statistics of China, as of 2018, the population of 0-14 years old was nearly 230 million (The National Bureau of Statistics of the People's Republic of China, 2018). This means that the huge group of children should be given enough attention in the construction of the healthcare system. At the same time, children, as a special group, have the characteristics of high morbidity and high outpatient rate. Because of these special characteristics, children under the same system cannot enjoy the same level of protection as other types of groups. Therefore, from the perspective of equal benefits, a healthcare system for children should be established, and the characteristics of the mechanism should be fully utilized to enable children to grow up healthily, which in turn is conducive to national development and social progress.
Equal benefits can be understood as the equalization state in the field of basic public services. There is a causal relationship between these. Equal benefits are the final effect to be achieved, and the equalization of basic public services is the way and actual performance to achieve equal benefit. At the present stage, the equalization of basic public services in China mainly includes three levels of meaning. The first level is that the central or local government should make clear provisions on the basic public services and standards in the area under its jurisdiction; the second level is that all residents should have the financial capacity to pay for basic public services and the central government (or the local government) must ensure that they do; the third level is that all residents should have the right and access to basic service facilities, irrespective of whether they are in urban or rural or regional areas (Ding, 2012).
Specific to the equal benefit in the field of children's healthcare, it mainly includes two aspects. First of all, as a special group in healthcare system, children should enjoy the same healthcare rights as other groups. Secondly, within the group, it is necessary to ensure that every child has the opportunity and the right to get the equal healthcare services. This requires the improvement of the corresponding medical service delivery system. Ensuring that children's healthcare resources are properly allocated at different levels of the healthcare delivery system will reduce the cost and enable more children to consume qualified healthcare services. The key to ensure that this system really works is the hierarchical diagnosis and treatment system and the corresponding incentive and restraint mechanism (Zhai & Xu, 2013). Among them, hierarchical diagnosis and treatment means that every child patient must first go to the specified Level I medical institution. If it cannot provide needed treatment, the doctor will issue a referral form allowing the child to be referred to the Level II medical institution, and the individual patient has no right to go beyond the Level II medical institution. In addition, when the patient's condition is alleviated, the patient needs to be transferred from a higher level to a lower level medical institution, namely, the mutual referral system. Hierarchical diagnosis and treatments distinguish the functions of medical institutions, promote the coordination and distribution of responsibilities among institutions, avoid disorderly and vicious competition and make the most effective use of medical resources. However, this grading system is an idealized design, and it is easily affected by information asymmetry, induced consumption and other phenomena in reality. Therefore, to make this system structure work in a healthy manner in reality, it is necessary to establish a supporting incentive and restraint mechanism.
This study applied the concept of health equal benefits and adopted the analytical framework of institutional analysis and mechanism design to conduct a systematic and in-depth theoretical and empirical research on the children's healthcare system based on a survey in Beijing, aiming at finding out problems and proposing relevant countermeasures and suggestions for the existing children's healthcare system in China.

| CHILD HEALTHCARE POLICIES IN BEIJING
In the implementation of the Healthy Beijing 2030 Plan of Action (2018-2020), Beijing government makes it clear that it should improve national healthcare system, which specifically includes improving health service system, medical insurance system and the pharmaceutical supply system and so on. In terms of optimizing child health services, it is mainly divided into infant and young child health services and adolescent health services. 1 Among them, health services for infants and young children include regular review of baby-friendly hospitals, improvement of the early childhood comprehensive development service referral network, training of healthcare personnel in kindergartens, strengthening health management of premature babies, health services for adolescents include establishing and improving

Key messages
• The construction of children's healthcare system in China needs to be given the priority.
• This study applied the concept of health equal benefits and conducted a systematic and in-depth theoretical and empirical research on the children's healthcare system in Beijing.
• The findings show that overall health of the children in Beijing was better.
• However, there are still problems such as insufficient resource coverage and incorrect cognition in some groups.
• This study draws policy attention to the issues of financing, service contents, targets, service level and the degree of social recognition. youth health service system, a joint supervision system for education and health and a student disease prevention and control model linked by families, schools and health institutions.
In terms of health education, the Health Month Activity themed 'Home and school work together to love and protect eyes' was carried out in Beijing, the work of 'Experts into the campus for health lectures' was continued, and a series of health education activities in primary and secondary schools were carried out by instructing parents and students to conduct health management 2 so as to ensure children's physical and mental health growth.
In terms of promoting the service of family doctors for children, Beijing has a total of 6378 family doctors and 4100 general practitioner teams. More than 7.4 million residents have signed up family doctors, with a total signing rate of 35% in 2019. 3

The Measures on Basic Medical Insurance for Urban and Rural
Residents of Beijing came into effect on 1 January 2018. In 2021, the reimbursement standard has been adjusted again, and the reimbursement ratio has been further refined, which is divided into outpatient and inpatient parts.
1. Outpatient reimbursement: The limit line for outpatient and emergency reimbursement in 2021 has been raised by RMB 500-RMB 4500. The starting line for medical institutions of the Level I and below is RMB 100/year, and 55% of the medical expenses within the scope of medical insurance can be reimbursed. The starting line for Level II and III medical institutions is RMB 550/year, and the medical expenses within the scope of medical insurance can be reimbursed by 50%.
2. Reimbursement of hospitalization: The limit line of reimbursement is RMB 250 000. The starting line of the Level I and below medical institutions is RMB 300/year, the medical expenses within the scope of medical insurance can be reimbursed by 80%; For Level II medical institutions, it is RMB 1300/year, and the medical expenses within the scope of medical insurance can be reimbursed by 78%. For Level III medical institutions, it is RMB 1300/year, and the medical expenses within the scope of medical insurance can be reimbursed by 75%-78%. 5 From 'One Elderly One Young' Policy to the transition of the Urban and Rural Residents' Basic Medical Insurance, this means that the construction of Beijing medical care system has been improved and demonstrated as multilevelled, which can be seen as gradually achieve the goal of 'everyone will have access to medical insurance' and at the same time also means that the more emphasis has been put on this special group of children increasingly and more rights and interests of the children have been effectively guaranteed. But medical care and healthcare of children are two different concepts that have shown up the transition from 'cure disease' to 'health'. So at this stage, there are still some problems in the children's health service supply in Beijing. The construction of the child healthcare system also needs to be gradually realized under the background of a sound universal healthcare system.

| Participants
In the process of the survey, the project team adopted the way of questionnaire on children's basic information, health status, health service demand, insured situation and system satisfaction and then analysed the children's health, healthcare services, satisfaction influence factors and their healthcare needs. Stratified sampling method was taken according to 16 administrative regions in Beijing. The objects of study are the children of 0-18 age group in Beijing and selected the children's parents, grandparents or other major guardians as targeted questionnaire respondents. Their willingness to participate in this survey was respected. The overall number was 5620, and this population is stratified by administrative region, and random sampling is carried out according to the ratio of sample size to the total number of 1:5. A total of 1124 questionnaires were selected in this survey, among which 1079 were valid, with an effective recovery rate of 96.00%.

| Procedure
Prior to collecting information, we first obtained the consents of the parents, grandparents or other major guardians. Online questionnaires were distributed to them. Respondents voluntarily completed the questionnaires. During the survey, the researcher and the team remained in contact, answered questions and mentored the participants' activity.

| Basic information
In this part, we made statistics on children's gender, age, household registration (health insurance system was based on this policy), average monthly household income and total monthly household expenditure. In the next part, we would use these statistics to evaluate the degree of equity and correlation between the child health and these factors.

| Child health status
In this part, we evaluated the children's physical and mental health.
For physical health, using a 5-point Likert scale (1 = excellent, 5 = not good), the child's general health was measured. And using 4-point Likert scale (1 = no change, 5 = hard to say), changes in child's health condition was measured. Physical examination and vaccination situation were also measured in this part.
For mental health, we focused on the general psychological condition using a 5-point Likert scale (1 = very happy, 5 = very unhappy).
In the meantime, we inquired the conditions of child's friendship and emotional support and guidance, as well as their after-school activities.

| Medical insurance status
In this part, we put emphasis on the participation and satisfaction with the medical insurance. For the satisfaction, we used a 5-point Likert scale (1 = very satisfied, 5 = very dissatisfied).

| Data analysis
In this paper, SPSS software is used to analyse the data obtained from the questionnaire survey. Methods such as descriptive statistics, analysis of variance and logistic regression are adopted to analyse the correlation between factors affecting children's health.

Children's mental health
The children interviewed are generally in good psychological condition. But there are still nearly 10% of children living without friends to share, which means that these children are more likely to live alone and thus need to pay more attention to their psychological changes.
Reasonable mental health education is particularly critical.
And it also indicated that most parents attached great importance to the child's emotional and mental health and gave timely guidance.
However, at the same time, there are still a very small number of parents that neglected to guide their children's emotions for some reasons, which should also play a corresponding role in such children's school and society so as to create a good psychological growth environment for children and ensure their mental health.

Participation in medical insurance
There are still 20% of the respondents who did not participate or did not understand the insurance policy. This shows that the popularization of medical insurance policies needs to be further improved.
There are a total of 494 cases of children with non-Beijing registration. Among them, 278 cases have participated in the medical insurance for urban and rural residents in their household registration, slightly more than 216 cases who have not participated in.
As for the sorts of medical insurances for children, generally speaking, the insurance status is good. More than 95% of the children have medical insurance, which provides a good protection for children's health. In addition, more than half of the respondents have purchased commercial insurance for their children, showing that they attach great importance to children's health, which is conducive to better implementation of children's health protection.

Analysis of satisfaction with insurance participation
Nearly 70% of the respondents thought that the procedures were convenient or very convenient, which shows that the convenience of procedures is generally accepted by the masses.
Among these 381 respondents who have experienced reimbursement, the convenience of reimbursement is satisfactory, but there is still room for improvement.
In the question of whether the burden of seeing a doctor is reduced or heavier compared with not being insured, it can be seen that the burden of seeing a doctor is slightly lower than before and the contribution to protecting children's health is not strong enough.
The effect of easing the burden is not obvious enough.
In the variable of 'satisfaction with the Basic Insurance', the statistics indicated that respondents were generally satisfied with the Basic Insurance.

| Correlation analysis of health, income and expenditure
The income variable was 'average monthly household income', the expenditure variable was 'total monthly household expenditure', and the health variable was 'overall physical health status of the child', 'overall mental health status of the child' and 'whether the child has had any illness in the past 6 months'. Because the variables are classified and ordered variables, the Spearman correlation coefficient is used for analysis. The respective Spear correlation coefficients are listed in the table, with P-values in brackets.
As can be seen from the correlation analysis in Table 2, just 'average monthly income' and 'whether the child has the illness within last six months' were a significant negative correlation. The P-value was 0.001, which was significant at the 1% significance level, indicating that the probability of the children in families with high monthly average income in the past 6 months was significantly lower than that of families with low monthly income.
None of the other variables passed the 5% significance test, indicating that the average monthly household income and monthly average expenditure are not statistically significant related to the child's physical and mental health. Children from families with higher income and expenditure are not better than children from families with lower expenditures are healthier, and there is no significant correlation between the average monthly expenditure and whether they are ill within 6 months.
The Spearman correlation coefficient and P-value of children's physical health and mental health were 0.496 and 0.001, respectively, which were significantly positively correlated at the 1% significance level, and the degree of correlation was very high, indicating that parents who believed that their children were physically healthy were also significantly inclined to believe that their children were mentally healthy. Further analysis was done to obtain the correlation coefficient between the satisfaction level and genders. The correlation coefficient was 0.069, and P was 0.024 and at the 5% significant level showed weak positive correlation level of significance. Because the satisfaction variable assignment from 1 to 5 is gradually diminishing, the gender variable 1 for male and 2 for the female, the positive coefficient indicated that male satisfaction was significantly higher than female. There was no significant difference in satisfaction among respondents with different marital status and different employment categories.
It can be seen from Table 4 that none of the four variables passed the Spearman correlation analysis at the 5% significance level.
Therefore, there was no statistically significant correlation between children's age, education level, average monthly family income, total monthly family expenditure and satisfaction.

| DISCUSSION
Through the above analysis on present situation of children's health in Beijing, it shows there are still some problems in children's health services, following mainly from the view of financing mechanism, service content, service level and degrees of social acceptance.

| The financing operation mechanism remains to be improved
The financing mechanism of the current Basic Medical Insurance System for Urban and Rural Residents (BMISUR) has been greatly improved compared with before, and the level of financial subsidies has been continuously increased, reducing the pressure on residents to seek medical treatment, but the overall financing mechanism still needs to be improved. First of all, in terms of financing structure, the government, society and individuals bear an unreasonable proportion of the responsibility.

| Service contents needs to be expanded and enriched
In the context of the Healthy China Strategy, the healthcare system includes not only physical health but also mental health, and the latter is particularly important. However, the analysis shows that children enjoy fewer mental health services and the service providers fail to realize the importance of mental health training for children. According to the survey, the child's age, mother's education level, the child's household registration, whether the child is covered by health insurance other than BMISUR, the area of residence and whether the child has been sick in the last 6 months are factors that influence whether the parents purchase BMISUR for the child. BMISUR is a voluntary-based insurance, and these influencing factors are key to expanding insurance coverage.

CONFLICT OF INTERESTS
The authors declared no potential conflicts of interest with respect to the research, authorship and/or publication of this article.

AUTHOR CONTRIBUTIONS
Qi Zhuang conceived of the study and wrote the manuscript. Yunzhi Peng helped to draft and Peter Coyte provided a variety of comments.
Jieyu Zhou performed the statistical analysis. Qi Zhuang, Yunzhi Peng, Jieyu Zhou and Peter Coyte participated in its design and coordination. All authors read and approved the final manuscript.

DATA AVAILABILITY STATEMENT
The data that support the findings of this study are available from the corresponding author upon reasonable request.